Sentinel Stroke National Audit Programme (SSNAP)

Results for Clinical Commissioning Groups (CCG) in England and Local Health Boards (LHB) in Wales

National results

Includes periodic (August 2017 – November 2017) and annual (April 2013 – March 2017) level results

Based on stroke patients admitted to and/or discharged from hospitals assigned to the relevant CCG/LHB

March 2018

Prepared by

Royal College of Physicians, Clinical Effectiveness and Evaluation Unit on behalf of the Intercollegiate Stroke Working Party

# Table of Contents

Introduction ........................................................................................................................................... 6\
Methods ................................................................................................................................................... 9\
Participation and Case Ascertainment................................................................................................. 10\
Section 1: Periodic Results .................................................................................................................. 13\
CCG Outcomes Indicator Set (OIS) ................................................................................................. 13\
Care delivered within the first 72h................................................................................................. 13\
Care delivered between 72h and discharge from inpatient care.............................................. 17\
6 month assessments .................................................................................................................... 19\
Further CCG Indicators .................................................................................................................... 21\
Atrial Fibrillation ......................................................................................................................... 21\
Early Supported Discharge (ESD) ............................................................................................... 21\
SSNAP Key Indicators ...................................................................................................................... 22\
Changes over time ....................................................................................................................... 30\
Section 2: Annual Results ..................................................................................................................... 32\
CCG Outcomes Indicator Set (OIS) ................................................................................................. 32\
Care delivered within the first 72h................................................................................................. 32\
Care delivered between 72h and discharge from inpatient care.............................................. 36\
Care delivered after discharge from inpatient care .................................................................... 39\
6 month assessments .................................................................................................................... 40\
Mortality data .................................................................................................................................... 43\
Further CCG Indicators .................................................................................................................... 45\
Atrial Fibrillation ......................................................................................................................... 45\
Early Supported Discharge (ESD) ............................................................................................... 45\
Institutionalisation ....................................................................................................................... 45\
SSNAP Key Indicators – annual results ............................................................................................ 47\
Conclusion............................................................................................................................................ 54 | Document purpose | To disseminate national periodic and annual results on the processes of stroke care at population level. | |------------------|--------------------------------------------------------------------------------------------------| | Title | CCG/LHB Public Report – Includes periodic (August 2017 - November 2017) and annual (April 2013-March 2017) level results | | Author | Royal College of Physicians, Clinical Effectiveness and Evaluation Unit on behalf of the Intercollegiate Stroke Working Party | | Publication | March 2018 | | Target audience | Clinical Commissioning Groups (CCGs), Local Health Boards (LHBs), general public, stroke survivors and carers, health and social care professionals, stroke researchers | | Description | This is the latest CCG/LHB level report on the clinical component (processes of care) of the national stroke audit, SSNAP. It includes results for those stroke care measures included in the CCG Outcomes Indicator Set and each of the 44 key indicators chosen by the Intercollegiate Stroke Working Party (ICSWP) as representative of high quality stroke care. It also highlights results for additional indicators including prior anticoagulation for patients in atrial fibrillation, and institutionalisation rates for patients discharged alive from hospital. More details on the measures reported on can be found in the introductory section of this document. The report is divided into two sections. Section 1 outlines national CCG/LHB results on the quality of stroke care for patients admitted and/or discharged between 1 August 2017 and 30th November 2017. Results for the three previous reporting periods are also provided so changes over time can be monitored. Section 2 outlines annual level results on four years’ worth of SSNAP data; for patients admitted and/or discharged between 1 April 2013 and 31 March 2014; 1 April 2014 and 31 March 2015; 1 April 2015 and 31 March 2016 and patients admitted and/or discharged between 1 April 2016 and 31 March 2017. The same stroke measures are reported in both sections of the report, with the exception of institutionalisation rates and mortality, which are only published annually. The report findings enable the processes of stroke services at population level to be compared with national standards outlined in the fifth edition of the National Clinical Guideline for Stroke (2016) published by the Intercollegiate Stroke Working Party, the National Institute for Health and Clinical Excellence (NICE) Clinical Guidelines, the National Stroke Strategy 2007 and the NICE Quality Standard for Stroke (2016). | | Supersedes | SSNAP Clinical Audit CCG/LHB April 2013 – March 2016 public report | | Related publications | **Present publications**\
SSNAP CCG/LHB Portfolio – February 2018\
[http://www.strokeaudit.org/results/National-Results.aspx](http://www.strokeaudit.org/results/National-Results.aspx)\
National clinical guideline for stroke 5th edition (Royal College of Physicians, 2016): [http://www.strokeaudit.org/guideline](http://www.strokeaudit.org/guideline)\
SSNAP Clinical audit public report – February 2018\
[https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx](https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx)\
SSNAP Full Results Portfolio – February 2018\
[https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx](https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx)\
SSNAP Acute Organisational Audit Report – September 2016:\
[http://www.strokeaudit.org/results/Organisational/National-Organisational.aspx](http://www.strokeaudit.org/results/Organisational/National-Organisational.aspx) | | Historical publications | |-------------------------| | National Sentinel Stroke Audit Clinical Report – May 2011: [http://www.rcplondon.ac.uk/sentinel](http://www.rcplondon.ac.uk/sentinel) | | SINAP Combined Quarters 1-7 Report – February 2013: [https://www.rcplondon.ac.uk/projects/outputs/sinap-data-transparency](https://www.rcplondon.ac.uk/projects/outputs/sinap-data-transparency) | | National clinical guidelines for diagnosis and initial management of acute stroke and transient ischaemic attack (NICE, 2008): [https://www.nice.org.uk/guidance/CG68](https://www.nice.org.uk/guidance/CG68) | | Stroke rehabilitation: Long-term rehabilitation after stroke (NICE 2013): [www.nice.org.uk/CG162](http://www.nice.org.uk/CG162) | | National Stroke Strategy (Department of Health, 2007): [http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062](http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062) | | Department of Health: Progress in improving stroke care (National Audit Office, 2010): [http://www.nao.org.uk/publications/0910/stroke.aspx](http://www.nao.org.uk/publications/0910/stroke.aspx) | | National Cardiovascular Outcomes Strategy – March 2013: [https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy](https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy) |

| Contact | ssnap@rcplondon.ac.uk | Report prepared by:

Mr Simon Bragg MSc SSNAP Data Coordinator, CEEu, Royal College of Physicians

Ms Lizz Paley MSc Stroke Programme Intelligence Manager—Data, CEEu, Royal College of Physicians

Mr Mark Kavanagh BA SSNAP Programme Manager, CEEu, Royal College of Physicians

Ms Victoria McCurran MPH SSNAP Senior Data Analyst, CEEu, Royal College of Physicians

Mrs Alex Hoffman MSc Stroke Programme Manager, CEEu, Royal College of Physicians

Professor Anthony Rudd FRCP CBE Chair of the Intercollegiate Stroke Working Party, Associate Director for Stroke (CEEu) Consultant Stroke Physician, Guy’s and St Thomas’ Hospital, London

Supported by:

Dr Martin James FRCP Associate Director for Stroke (CEEu) Consultant Stroke Physician, Royal Devon and Exeter Hospital, Devon Introduction

This report aims to provide commissioners of stroke services [Clinical Commissioning Groups (CCGs) in England and Local Health Boards (LHBs) in Wales], other interested stakeholders within the NHS, and the general public with key information on the population receiving stroke care according to the CCG/LHB assigned to patients, at national level and over time. This report should be read in conjunction with other outputs (outlined on page 7) that are designed to help drive quality improvement. This report is based on data submitted to the Sentinel Stroke National Audit Programme (SSNAP). SSNAP is a prospective clinical audit that measures the quality of stroke care delivered to every stroke patient across all providers; from initial admission up to 6 months when outcomes are measured. SSNAP is the single source of stroke data in England and Wales.

What is included in this report

CCG Outcomes Indicator Set (CCG OIS measures) The report includes results for the CCG Outcomes Indicator Set (CCG OIS). The CCG OIS is a set of measures by which commissioners of health services in England are held to account for the quality of services and the health outcomes achieved by their commissioning. http://www.england.nhs.uk/ccg-ois. The data are also analysed for Wales as this information is relevant to all stroke care. The report also contains two measures which are of high priority for stroke work across many CCGs and LHBs: prior anticoagulation of stroke patients who are admitted to hospital and known to be in atrial fibrillation; and treatment by stroke skilled Early Supported Discharge teams (ESDs). Maps are used to present these results at both periodic and annual level throughout this report and Appendix 1 gives a breakdown of the number and percentage of CCGs/LHBs achieving each level for the CCG OIS measures and overall SSNAP score at annual and periodic level. All of the data is available in the CCG/LHB Portfolio. More details about this portfolio are given below in the Further Information section.

SSNAP Key Indicators All 44 of the SSNAP 'Key Indicators' are included in this report, giving a broad picture of stroke care across inpatient care providers. This enables the processes of stroke services at national level to be compared with national standards outlined in the fifth edition of the National Clinical Guideline for Stroke (2016) published by the Intercollegiate Stroke Working Party, the National Institute for Health and Care Excellence (NICE) Clinical Guidelines, the National Stroke Strategy (2007) and the NICE Quality Standard for Stroke (2016). How to read this report The report presents results at both a periodic and annual level across recent SSNAP reporting periods to enable changes over time to be monitored. Section 1 of the report presents results for all patients admitted (or having a stroke as an inpatient) and/or discharged from hospital across 4 reporting periods between August 2016 and November 2017. Section 2 presents results for each of the four years: April 2013 to March 2014, April 2014 to March 2015, April 2015 to March 2016, and April 2016 to March 2017.

Please note that as of April 2016, SSNAP began reporting periodically over a four monthly reporting period, rather than every three months as with all previous reporting periods.

By highlighting the performance of each CCG in England and LHB in Wales for key indicators of care it is possible to develop a national picture of stroke services in England and Wales, identify where variations in the quality of services exist and where improvements are being made. It is hoped that these results will help commissioning groups to identify how their patients are being treated, and enable healthcare professionals and the public to identify the strengths of current service provision and the areas where improvements are needed.

Further Information Those who work within the NHS, such as within a CCG or LHB, should register themselves on the SSNAP webtool at www.strokeaudit.org by following the path under “Registration”. This will give them privileged access to SSNAP results for a period of time before they are put into the public domain. They can also benefit from a helpdesk that exists to help them interpret their results and drive quality improvement in their local service. Registration is quick and simple to do.

Additional Reports available The CCG/LHB Results portfolio gives results for individual CCGs and LHBs for every measure in the CCG OIS and each SSNAP Key Indicator. It is produced every four months and on an annual basis. This excel file contains a list of all of the hospitals (teams) to which each CCG’s/LHB’s patients were admitted and further details about the methodology used in the analysis of results. The portfolio also gives the names of each of the hospital(s) where CCG/LHB patients were treated and details levels of case ascertainment achieved by each CCG/LHB. To access this portfolio go to: https://www.strokeaudit.org/results/Clinical/National-Results.aspx

SSNAP also produces Interactive Maps that give a visual representation of hospitals’ performance within each CCG/LHB. Go to https://www.strokeaudit.org/results/Clinical-audit/Maps to access these maps. Once domain or key indicator results have been selected, click on CCG boundaries in the box on the bottom right of the screen to highlight which hospitals are within each CCG. This CCG/LHB report is supplementary to the full SSNAP Public Report which is published every four months and reports on every measure collected by SSNAP according to the team or series of teams treating the patient. It also includes contextual information, further details about specific SSNAP Key Indicators and clinical commentary on performance at a national level against evidence based standards.

**Health Economics on SSNAP**

SSNAP has recently produced a Health Economics section of the webtool that allows people, including those who commission services, to see the financial implications from implementing certain interventions such as thrombolysis or increasing the number of patients discharged from hospital with an ESD team. This is currently available here: [https://www.strokeaudit.org/Health-Economics.aspx](https://www.strokeaudit.org/Health-Economics.aspx)

**A note on results for Local Health Boards**

SSNAP has been advised that Local Health Boards are the best approximation of CCGs. While the CCG Outcomes Indicator Set is applicable to CCGs in England only, results for LHBs in Wales are also included in the CCG portfolio to enable the results for these important indicators to be used for quality improvement purposes in Wales, and allow comparability across England and Wales. Results by named LHB have been included in the CCG portfolio since the January – March 2015 report. Methods

Data Collection A core, minimum dataset was developed by the Intercollegiate Stroke Working Party (ICSWP) in collaboration with other key stakeholders. Prospective data were collected via a secure web-based tool provided by Netsolving Ltd. Security and confidentiality were maintained through the use of passwords and a person specific registration process. Detailed help notes and FAQs were provided to ensure standard interpretation of the dataset questions across all participants. Data were analysed by the Stroke Programme at the Royal College of Physicians.

Only ‘locked’ data are included in SSNAP analysis. The process of locking ensures high data quality and signifies that the data have been signed off by the lead clinician and are ready for central analysis. To view the SSNAP core dataset and help-notes, and for more details about the methods of data collection, submission, and analysis, please visit: https://www.strokeaudit.org/Support/New-SSNAP-Users.aspx

Assigning patients to CCGs/LHBs The preferred methodology for CCG/LHB analysis would assign patients to a CCG/LHB based on the patient’s GP practice. However as this information is not collected by SSNAP, a postcode of residence is used to assign patients to a CCG/LHB. Participation and Case Ascertainment

Case ascertainment is a vital component of SSNAP as the aim is to have fully complete data on every new stroke admission. It measures the proportion of stroke cases entered onto SSNAP. High levels of case ascertainment are essential to ensure representativeness.

Please note that CCGs/LHBs with less than 50% case ascertainment or fewer than 20 patients do not receive all results.

This table below presents the number of records included in SSNAP across all CCGs and LHBs as a percentage of the estimated expected number of patients from Hospital Episode Statistics (HES) for the previous four reporting periods. The five bandings for average case ascertainment are shown in the legends for the maps on the next page. The national average case ascertainment band for CCG/LHB reporting is currently an A (90%+).

| National average case ascertainment band | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |-----------------------------------------|--------------|-------------------|--------------|--------------| | 80-89% | 211/216 | 215/216 | 212/214 | 214/214 | | 90%+ | 101 | 105 | 103 | 106 |

The CCGs/LHBs not included in each reporting period’s SSNAP scoring due to insufficient records are given below.

| Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |--------------|-------------------|--------------|--------------| | Hastings and Rother CCG | Tower Hamlets CCG | North East Hampshire and Farnham CCG | (None) | | North Durham CCG | | Lewisham CCG | | | Durham Dales, Easington and Sedgefield CCG | | | | | Darlington CCG | | | | | Havering CCG | | | |

Denominators for CCG/LHBs

SSNAP derives CCG/LHB denominators from Hospital Episode Statistics (HES) data for England and Patient Episode Database for Wales (PEDW). Case Ascertainment Maps The following maps show the average case ascertainment bandings achieved by all CCGs/LHBs. Each symbol represents a CCG/LHB, colour coded by band. The map below shows the average case ascertainment bandings achieved by all CCGs/LHBs from the most recent annually reported data.

Average Case Ascertainment Apr 2016 – Mar 2017

SSNAP participation

Source: SSNAP Apr 2016 - Mar 2017 Section 1: Periodic Results

CCG Outcomes Indicator Set (OIS)

In this section of the report, CCG OIS measures are divided into three groups: "Care delivered within the first 72h", "Care delivered between 72h and discharge from inpatient care" and "Care delivered after discharge from inpatient care". All groups are based on patients either admitted to or discharged from inpatient care across 4 reporting periods between August 2017 – November 2017. The results for the most recent reporting period are highlighted in bold. The ‘Ref’ column refers to where each result can be found in the Results Portfolio. The national row gives the total number of patients assigned to CCGs/LHBs that are included in the results for each reporting period.

Care delivered within the first 72h

Direct to stroke unit within 4 hours

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------------|--------------|-------------------|--------------|--------------|-----| | National | N=25629 | N=26753 | N=26442 | N=26778 | | | Percentage of applicable patients who go direct to a stroke unit within 4 hours (CCG OIS - C3.5) | 59.3% | 55.6% | 60.9% | 59.5% | G7.18.1 |

Exclusion Criteria for admission to stroke unit within 4 hours

Those patients first admitted to an Intensive Therapy Unit (ITU), Coronary Care Unit (CCU), or High Dependency Unit (HDU) are not applicable for this key indicator. From Jan-Mar 2016, patients that receive a thrombectomy are also excluded.

Percentage of applicable patients who go direct to a stroke unit within 4 hours

Source: SSNAP August-November 2017 The number of patients being admitted to a stroke unit within 4 hours between August – November 2017 impacted the overall levels achieved by hospitals for the Stroke Unit domain. This domain also includes the median time taken to be admitted to a stroke unit, and the percentage of patients who spend at least 90% of their inpatient stay in a stroke unit. The stacked chart below visually demonstrates the fluctuations in performance within this domain in recent reporting periods. This reporting period has seen a slight increase in the number of E bandings being awarded.

The evidence for stroke units is very strong and it is important to monitor changes to rates in stroke unit admissions over time. The percentage of applicable patients directly admitted to a stroke unit within 4 hours of arrival at hospital was 59.5% in the latest reporting period, an decrease from the previous reporting period where we reported 60.9%. In the previous seven reporting periods, this indicator has fluctuated, tending to fall in winter months. A poor performance in this key indicator will often mean that other standards will fall. It is concerning when performance drops, and results for this key indicator should be closely monitored. Domain 2: Stroke unit scores over time

Source: SSNAP 2017 Stroke patients who receive thrombolysis

Percentage of eligible patients given thrombolysis (according to the RCP guideline minimum threshold)

Though the percentage of eligible patients given thrombolysis (according to RCP guideline minimum threshold) is not included in the CCG OIS, it is important to highlight the year on year change in this indicator of quality stroke care. In April 2015 – March 2016, 85.2% of eligible patients were thrombolysed, but between April 2016 – March 2017, this percentage had increased to 87.1%. Between December 2016 – March 2017, this marginally dropped to 85.6%, before increasing again to 87.3% from April 2017 – July 2017 and increasing again in August – November 2017 to 88.1%.

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------|--------------|-------------------|--------------|--------------|-----| | National | N=26291 | N=27489 | N=27135 | N=27583 | | | Percentage of all stroke patients who receive thrombolysis (CCG OIS - C3.6) | 11.4% | 11.4% | 11.9% | 11.1% | G16.3 |

Percentage of all patients who receive thrombolysis

![Map showing percentage of patients receiving thrombolysis](image)

CCG OIS - C3.6 Source: SSNAP August-November 2017

### Care delivered between 72h and discharge from inpatient care

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------------|--------------|-------------------|--------------|--------------|-----| | National | N=11814 | N=12207 | N=11817 | N=11746 | | | Percentage of applicable patients who are discharged with joint health and social care plan (CCG OIS - C3.7) | 90.2% | 89.7% | 90.5% | 93.8% | J33.13 |

#### Percentage of applicable patients who are discharged with joint health and social care plan

- **90.0%**
- **80.0%-89.9%**
- **75.0%-79.9%**
- **60.0%-74.9%**
- **\<60.0%**
- Insufficient records

Source: SSNAP August-November 2017

______________________________________________________________________

CCG OIS - C3.7 Source: SSNAP August-November 2017 Over 90% of inpatient stay on a stroke unit

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------------|--------------|-------------------|--------------|--------------|-----| | National | N=25169 | N=26438 | N=26165 | N=26443 | | | Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit (CCG OIS - C3.9) | 85.2% | 83.1% | 85.0% | 85.1% | J8.11 |

Exclusion Criteria

If a hospital admitted patients who went directly to an Intensive Therapy Unit (ITU), Coronary Care Unit (CCU), or High Dependency Unit (HDU), those patients are excluded from this indicator. Patients who died on the same day as arrival/onset of symptoms are also excluded.

Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

Source: SSNAP August-November 2017 Care delivered after discharge from inpatient care

6 month assessments

Collection of six month outcome data is key to assessing the outcomes of stroke care and forms part of the CCG OIS that is reported periodically in England.

It is extremely important that data regarding a patient’s status and outcome at six months after their stroke is recorded on SSNAP. Without this data the outcomes of the care that patients receive cannot be fully assessed. Unfortunately a high percentage of patients are not receiving this follow up. SSNAP reports the completion rate of those considered applicable for this assessment. These data have the potential to reveal variations in access to six month assessments across the country. In cases where six month assessments are being provided but are not recorded on SSNAP, valuable information about patient outcomes post stroke is being missed. Phase 1 of the post-acute organisational audit reported 54% of CCGs/LHBs commissioned this service yet in the latest reporting period only 30.5% of applicable patients received a six month assessment as reported by SSNAP. This percentage needs to be improved.

CCG/LHBs should use SSNAP data to monitor provision of six month assessments. If patients in your area are not currently being offered a six month assessment or they are not being commissioned, action plans should be made to address this. The below table shows the overall percentage of patients who are alive that could be benefitting from a six month assessment.

**Patient applicability for 6 month assessment**

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------------|--------------|-------------------|--------------|--------------|-----| | N | 21927 | 22490 | 20389 | 21093 | | | Percentage of patients alive who are considered applicable to be assessed at 6 months | 92.3% | 92.1% | 92.3% | 91.6% | B12.3 |

Patients are considered not applicable for a six month assessment if they refused their assessment after being contacted, and/or did not attend their scheduled assessment when they were due to have their assessment, or if they are known to have died before their assessment is due.

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------------|--------------|-------------------|--------------|--------------|-----| | N | 20243 | 20716 | 18821 | 19322 | | | Percentage of applicable patients who are assessed at 6 months (CCG OIS 3.8) | 31.3% | 28.5% | 31.3% | 30.5% | B13.3 | Completion rate of 6 month follow-up assessments for applicable patients on SSNAP

Percentage of applicable patients who are assessed at 6 months

- 80.0%+
- 60.0%-79.9%
- 40.0%-59.9%
- 20.0%-39.9%
- \<20.0%
- Insufficient records

Source: SSNAP August-November 2017

CCG OIS - C3.8 Source: SSNAP August-November 2017 Further CCG Indicators

Atrial Fibrillation SSNAP data has revealed major issues in primary and secondary care about ensuring that patients have effective primary stroke prevention. One fifth of patients are in atrial fibrillation (AF) on admission. Only 58.7% of patients reported to be in AF prior to admission are taking anticoagulants. Though this percentage is incrementally increasing over time, more work needs to be done in primary care to ensure people who would benefit from anticoagulants are provided with this medication. Unfortunately 14.1% are taking antiplatelet drugs alone which are considered ineffective for most patients in AF.

Prior anticoagulation for patients known to be in atrial fibrillation prior to being admitted to hospital for stroke

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | Ref | |----------------------|--------------|-------------------|--------------|--------------|-----| | N | N=5111 | N=5505 | N=5149 | N=5259 | | | Percentage of patients in AF admitted to hospital for stroke who had been prescribed anticoagulation prior to their stroke | 53.5% | 54.0% | 56.2% | 58.7% | F6.13 |

Early Supported Discharge (ESD) ESD is defined as a service providing rehabilitation and support to stroke patients in a community setting, usually at home, by a multidisciplinary team with the aim of reducing the duration of hospital care for stroke patients. The rehabilitation provided to patients should be at the same intensity as inpatient care. ESD should be stroke specific and delivered by teams with specialist stroke skills. According to literature, approximately 34% of stroke patients are considered eligible for ESD. Phase 1 of the post-acute organisational audit reported that 82% of CCGs in England and 67% of LHBs in Wales commissioned ESD services as of 1 December 2014. ESD can result in better outcomes including reduction of long-term mortality and institutionalisation rates, increased independence six months after a stroke and increased capacity to undertake activities of daily living and greater patient satisfaction (Langhorne et al 2005). Benefits for hospitals include a reduced length of stay. Treatment by a stroke skilled Early Supported Discharge team

SSNAP Key Indicators

44 Key Indicators have been chosen by the Intercollegiate Stroke Working Party (ICSWP), a multidisciplinary steering group that guide the audit, as representative of high quality stroke care. These indicators include data items from the CCG Outcomes Indicator Set and NICE Quality Standards (covering England only). The key indicators are grouped into 10 domains covering key aspects of the process of stroke care, such as “Brain scanning” or “Physiotherapy”. The following section of this report gives the results for each key indicator at CCG/LHB level for the 4 most recent reporting periods which enables changes over time to be measured.

The term ‘clock start’ is used to identify the time at which the ‘clock starts’ for measuring key timings. This is arrival time for patients who were not in hospital at the onset of symptoms (around 95% of patients) but will be the onset of symptoms time for those patients already in hospital when they have a stroke (approximately 5% of stroke cases).

Brain Scanning Key Indicators

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |--------------------------------|--------------|-------------------|--------------|--------------| | **1.1 Percentage of patients scanned within 1 hour of clock start** | 51.0 | 52.6 | 52.7 | 52.9 | | **1.2 Percentage of patients scanned within 12 hours of clock start** | 93.9 | 94.3 | 94.4 | 94.6 | | **1.3 Median time between clock start and scan (hours:mins)** | 0:58 | 0:55 | 0:55 | 0:54 |

Stroke Unit Key Indicators

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |--------------------------------|--------------|-------------------|--------------|--------------| | **2.1 Percentage of patients directly admitted to a stroke unit within 4 hours of clock start** | 59.3 | 55.6 | 60.9 | 59.5 | | **2.2 Median time between clock start and arrival on stroke unit (hours:mins)** | 3:36 | 3:45 | 3:30 | 3:34 | | **2.3 Percentage of patients who spent at least 90% of their stay on stroke unit** | 85.2 | 83.1 | 85.0 | 85.1 |

### Thrombolysis Key Indicators

| Indicator | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |---------------------------------------------------------------------------|--------------|-------------------|--------------|--------------| | **3.1 Percentage of all stroke patients given thrombolysis (all stroke types)** | 11.4 | 11.4 | 11.9 | 11.1 | | **3.2 Percentage of eligible patients (according to the RCP guideline minimum threshold) given thrombolysis** | 88.3 | 85.6 | 87.3 | 88.1 | | **3.3 Percentage of patients who were thrombolysed within 1 hour of clock start** | 62.9 | 62.1 | 64.0 | 63.7 | | **3.4 Percentage of applicable patients directly admitted to a stroke unit within 4 hours of clock start AND who either receive thrombolysis or have a pre-specified justifiable reason ('no but') for why it could not be given** | 58.9 | 55.1 | 60.6 | 59.4 | | **3.5 Median time between clock start and thrombolysis (hours:mins)** | 0:51 | 0:52 | 0:50 | 0:50 |

### Specialist Assessments Key Indicators

| Indicator | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |---------------------------------------------------------------------------|--------------|-------------------|--------------|--------------| | **4.1 Percentage of patients assessed by a stroke specialist consultant physician within 24h of clock start** | 82.2 | 81.3 | 83.0 | 84.6 | | **4.2 Median time between clock start and being assessed by stroke consultant (hours:mins)** | 11:00 | 11:01 | 10:23 | 8:32 | | **4.3 Percentage of patients who were assessed by a nurse trained in stroke management within 24h of clock start** | 90.6 | 89.9 | 90.8 | 91.3 | | **4.4 Median time between clock start and being assessed by stroke nurse (hours:mins)** | 1:13 | 1:09 | 1:05 | 1:06 | | **4.5 Percentage of applicable patients who were given a swallowscreen within 4h of clock start** | 74.6 | 74.1 | 76.1 | 76.7 | | **4.6 Percentage of applicable patients who were given a formal swallow assessment within 72h of clock start** | 87.7 | 87.4 | 87.8 | 88.8 |

### Occupational Therapy Key Indicators

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |--------------------------------|--------------|-------------------|--------------|--------------| | **5.1** Percentage of patients reported as requiring occupational therapy | 83.6 | 84.6 | 84.7 | 84.0 | | **5.2** Median number of minutes per day on which occupational therapy is received | 40.7 | 40.0 | 40.0 | 40.2 | | **5.3** Median % of days as an inpatient on which occupational therapy is received | 65.2 | 64.6 | 65.3 | 67.0 | | **5.4** Compliance (%) against the therapy target of an average of 25.7 minutes of occupational therapy across all patients *(Target = 45 minutes x (5/7) x 0.8 which is 45 minutes of occupational therapy x 5 out of 7 days per week x 80% of patients)* | 86.2 | 85.0 | 86.0 | 88.0 |

### Physiotherapy Key Indicators

| | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |--------------------------------|--------------|-------------------|--------------|--------------| | **6.1** Percentage of patients reported as requiring physiotherapy | 85.2 | 86.6 | 86.1 | 85.0 | | **6.2** Median number of minutes per day on which physiotherapy is received | 35.0 | 35.0 | 35.0 | 35.0 | | **6.3** Median % of days as an inpatient on which physiotherapy is received | 74.0 | 71.6 | 73.1 | 75.6 | | **6.4** Compliance (%) against therapy target of an average of 27.1 minutes of physiotherapy across all patients *(Target = 45 minutes x (5/7) x 0.85 which is 45 minutes of physiotherapy x 5 out of 7 days x 85% of patients)* | 80.7 | 79.4 | 80.6 | 82.3 |

### Speech and Language Therapy Key Indicators

| Indicator | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |---------------------------------------------------------------------------|--------------|-------------------|--------------|--------------| | **7.1 Percentage of patients reported as requiring speech and language therapy** | 50.9 | 51.5 | 51.2 | 50.1 | | **7.2 Median number of minutes per day on which speech and language therapy is received** | 31.7 | 31.7 | 31.7 | 32.0 | | **7.3 Median % of days as an inpatient on which speech and language therapy is received** | 48.2 | 48.0 | 49.8 | 51.2 | | **7.4 Compliance (%) against the therapy target of an average of 16.1 minutes of speech and language therapy across all patients (Target = 45 minutes x (5/7) x 0.5 which is 45 minutes of speech and language therapy x 5 out of 7 days per week x 50% of patients)** | 48.3 | 48.8 | 50.2 | 51.1 |

### Multidisciplinary Team Working Key Indicators

| Indicator | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |---------------------------------------------------------------------------|--------------|-------------------|--------------|--------------| | **8.1** Percentage of applicable patients who were assessed by an occupational therapist within 72h of clock start | 92.1 | 91.7 | 92.2 | 93.1 | | **8.2** Median time between clock start and being assessed by occupational therapist (hours:mins) | 21:33 | 21:40 | 21:13 | **21:16** | | **8.3** Percentage of applicable patients who were assessed by a physiotherapist within 72h of clock start | 95.2 | 94.5 | 94.9 | 95.7 | | **8.4** Median time between clock start and being assessed by physiotherapist (hours:mins) | 20:46 | 21:08 | 20:38 | **20:38** | | **8.5** Percentage of applicable patients who were assessed by a speech and language therapist within 72h of clock start | 89.5 | 88.2 | 89.4 | **90.1** | | **8.6** Median time between clock start and being assessed by speech and language therapist (hours:mins) | 22:55 | 23:17 | 22:51 | **22:43** | | **8.7** Percentage of applicable patients who have rehabilitation goals agreed within 5 days of clock start | 92.0 | 92.5 | 92.4 | **92.3** | | **8.8** Percentage of applicable patients who are assessed by a nurse within 24h AND at least one therapist within 24h AND all relevant therapists within 72h AND have rehab goals agreed within 5 days | 62.8 | 61.3 | 63.6 | **64.8** |

### Standards by Discharge Key Indicators

| Indicator | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |---------------------------------------------------------------------------|--------------|-------------------|--------------|--------------| | 9.1 Percentage of applicable patients screened for nutrition and seen by a dietitian by discharge | 83.5 | 82.8 | 82.4 | 80.7 | | 9.2 Percentage of applicable patients who have a continence plan drawn up within 3 weeks of clock start | 92.1 | 91.7 | 92.9 | 94.2 | | 9.3 Percentage of applicable patients who have mood and cognition screening by discharge | 92.0 | 91.9 | 91.7 | 91.8 |

### Discharge Processes Key Indicators

| Indicator | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |---------------------------------------------------------------------------|--------------|-------------------|--------------|--------------| | 10.1 Percentage of applicable patients receiving a joint health and social care plan on discharge | 90.2 | 89.7 | 90.5 | 93.8 | | 10.2 Percentage of patients treated by a stroke skilled Early Supported Discharge team | 35.1 | 35.8 | 33.8 | 35.1 | | 10.3 Percentage of applicable patients in atrial fibrillation on discharge who are discharged on anticoagulants or with a plan to start anticoagulation | 97.5 | 97.9 | 98.2 | 98.1 | | 10.4 Percentage of those patients who are discharged alive who are given a named person to contact after discharge | 96.8 | 96.9 | 96.8 | 97.1 | **Overall SSNAP level**

The RCP stroke programme has calculated SSNAP levels that indicate the average level attributed to providers within your CCG/LHB. The SSNAP level is based on providers’ performance within 10 domains of care which comprise 44 key indicators. This combined key indicator score is adjusted for providers’ case ascertainment and audit compliance. The map below shows the average SSNAP level within each CCG/LHB for the quality of care delivered for patients admitted and/or discharged between 1 August 2017 to 30 November 2017.

**Assigning a SSNAP score**

The SSNAP score for CCGs and LHBs is a weighted average of the scores that the hospitals treating the patients received. The weights are based on how many patients within that CCG/LHB each hospital treated. So if 100 patients from CCG 00C had strokes, and 50 went to hospital A, 25 to hospital B and 25 to hospital C then that CCG’s score is 0.5*hospital A’s score + 0.25*hospital B’s score + 0.25\*hospital C’s score.

Overall SSNAP levels for individual CCGs/LHBs can be found in SSNAP’s CCG/LHB results portfolio.

**Average CCG/LHB SSNAP score**

Source: SSNAP August-November 2017 Changes over time

The maps below show the average SSNAP level for providers for all CCGs/LHBs across the past four reporting periods (August – November 2016; December 2016 – March 2017; April 2017 – July 2017; August – November 2017). We are providing information on how the current results compare with the previous reporting periods for an indication of where changes in the quality of stroke care are happening. Hospital level reporting

This section gives details of changes in SSNAP performance over time at individual inpatient team (or stroke service) level rather than CCG/LHB level to further highlight the overall improvements to stroke services over the past four reporting periods.

The stacked graph below highlights how providers’ SSNAP levels have changed over time at national level. These graphs clearly demonstrate that improvements in stroke services have been made with significantly more ‘A’ - ‘B’s and fewer ‘D’ - ‘E’s in August 2017 – November 2017 than April – June 2014.

This table shows the distribution of SSNAP levels across inpatient teams for the last four reporting periods.

| SSNAP Levels | Aug-Nov 2016 218 teams | Dec 2016-Mar 2017 225 teams | Apr-Jul 2017 219 teams | Aug-Nov 2017 219 teams | |--------------|------------------------|-----------------------------|------------------------|------------------------| | A | 41 teams (19%) | 36 teams (16%) | 51 teams (23%) | 44 teams (20%) | | B | 60 teams (28%) | 60 teams (27%) | 62 teams (28%) | 79 teams (36%) | | C | 64 teams (29%) | 61 teams (27%) | 56 teams (26%) | 49 teams (22%) | | D | 49 teams (22%) | 56 teams (25%) | 45 teams (21%) | 43 teams (20%) | | E | 4 teams (2%) | 12 teams (5%) | 5 teams (2%) | 4 teams (2%) |

Source: SSNAP 2017 Section 2: Annual Results

CCG Outcomes Indicator Set (OIS)

In this section of the report, CCG OIS measures are divided into four groups: "Care delivered with the first 72h", "Care delivered between 72h and discharge from inpatient care", "Care delivered after discharge from inpatient care" and “Patient Outcomes”. All groups are based on patients either admitted to or discharged from inpatient care across 4 years between April 2013 and March 2017.

Care delivered within the first 72h

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | National | N=72013 | N=78199 | N=80026 | N=79835 | | | Percentage of applicable patients who go direct to a stroke unit within 4 hours (CCG OIS - C3.5)\* | 58.1% | 56.9% | 59.0% | 58.2% | G7.18.1 |

\*From April 2015 – March 2016 patients who had a thrombectomy are excluded from this indicator

Direct to stroke unit within 4 hours

Percentage of applicable patients who go direct to a stroke unit within 4 hours

| Percentage of applicable patients who go direct to a stroke unit within 4 hours | |---------------------------------| | 90.0%+ | | 75.0%-89.9% | | 60.0%-74.9% | | 55.0%-59.9% | | \<55.0% | | Insufficient records |

CCG OIS - C3.5 Source: SSNAP Apr 2016 - Mar 2017 Stroke patients who receive thrombolysis

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | N=73422 | N=79721 | N=81865 | N=81978 | | | | Percentage of all stroke patients who receive thrombolysis (CCG OIS - C3.6) | 11.6% | 11.6% | 11.1% | 11.6% | G16.3 |

Percentage of all patients who receive thrombolysis

- 20.0+%
- 15.0%-19.9%
- 12.0%-14.9%
- 10.0%-11.9%
- \<10.0%
- Insufficient records

Source: SSNAP Apr 2016 - Mar 2017 Care delivered between 72h and discharge from inpatient care

Discharged with joint health and social care plan

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|--------------------------|-------------------------|-------------------------|-------------------------|-----| | N=30263 | N=35990 | N=35786 | N=36535 | | | | Percentage of applicable patients who are discharged with joint health and social care plan (CCG OIS - C3.7) | 69.1% | 81.0% | 87.6% | 90.0% | J33.13 |

Percentage of applicable patients who are discharged with joint health and social care plan

- 90.0+%%
- 80.0%-89.9%
- 75.0%-79.9%
- 60.0%-74.9%
- \<60.0%
- Insufficient records

CCG OIS - C3.7 Source: SSNAP Apr 2016 - Mar 2017

London

Source: SSNAP Apr 2016 - Mar 2017 Percentage of applicable patients who are discharged with joint health and social care plan

CCG OIS - C3.7 Source: SSNAP Apr 2015 - Mar 2016

Percentage of applicable patients who are discharged with joint health and social care plan

CCG OIS - C3.7 Source: SSNAP Apr 2014 - March 2015

Percentage of applicable patients who are discharged with joint health and social care plan

CCG OIS - C3.7 Source: SSNAP Apr 2013-Mar 2014

SSNAP CCG/LHB Public Report (March 2018) Over 90% of inpatient stay on a stroke unit

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | N=64748 | N=75962 | N=77714 | N=78688 | | | | Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit (CCG OIS - C3.9) | 83.0% | 82.0% | 83.9% | 84.2% | J8.11 |

Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

- 90.0+%
- 85.0%-89.9%
- 80.0%-84.9%
- 75.0%-79.9%
- \<75.0%
- Insufficient records

CCG OIS - C3.9\
Source: SSNAP Apr 2016 - Mar 2017 Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

CCG OIS - C3.9 Source: SSNAP Apr 2015 - Mar 2016

Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

CCG OIS - C3.9 Source: SSNAP Apr 2014 - March 2015

Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

CCG OIS - C3.9 Source: SSNAP Apr 2013-Mar 2014

SSNAP CCG/LHB Public Report (March 2018) Care delivered after discharge from inpatient care

6 month assessments

Collection of six month outcome data is key to assessing the outcomes of stroke care and forms part of the CCG OIS that was reported in December 2014, December 2015 and December 2016 in England. CCG/LHBs should use SSNAP data to monitor provision of six month assessments. If patients in your area are not currently being offered a six month assessment or they are not being commissioned, action plans should be made to address this. Further information on 6 month assessments can be found on page 18 of this report.

Patient applicability for 6 month assessment

Patients are considered not applicable for a six month assessment if they refused their assessment after being contacted, and/or did not attend their scheduled assessment, and/or had died prior to the time period when they were due to have their assessment.

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | N=27668 | N=60028 | N=61096 | N=65382 | | | | Percentage of patients alive who are considered applicable to be assessed at 6 months | 92.0% | 94.9% | 93.4% | 91.8% | B12.3 |

Completion rate of 6 month follow-up assessments for applicable patients on SSNAP

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | N=25446 | N=56982 | N=57041 | N=60016 | | | | Percentage of applicable patients who are assessed at 6 months (CCG OIS 3.8) | 16.2% | 21.9% | 30.0% | 31.9% | B13.3 | Percentage of applicable patients who are assessed at 6 months

CCG OIS - C3.8 Source: SSNAP Apr 2016 - Mar 2017

Source: SSNAP Apr 2016 - Mar 2017 Mortality data

We are now reporting mortality rates by CCGs/LHBs for the year April 2016 to March 2017. Unlike the Dr Foster data, we have adjusted for case mix including stroke severity. The model used for this has been published in Stroke, and the published paper shows that the model is very reliable when externally validated. Briefly, the model takes account of the age of the patient, whether they have a prior diagnosis of atrial fibrillation (AF), stroke type (haemorrhage or infarction), and the NIHSS score at arrival (where this is not fully completed, the level of consciousness at arrival).

Having a higher than expected mortality should not necessarily be interpreted as being the result of poorer quality or unsafe care. Mortality data should not be ignored but needs to be understood in the context of the other SSNAP data and other factors. For example, mortality rates could be affected by the quality or accuracy of the data or by patient characteristics that were not taken into account when calculating the adjusted mortality rates, such as social deprivation. CCGs/LHBs should use the data to help better understand mortality in their patients.

Data submitted to SSNAP for patient admissions has been linked with data from the Office for National Statistics in order to determine all cause mortality for the patients with known stroke type admitted between April 2016 and March 2017. The number of deaths recorded within 30 days of admission (or stroke onset if inpatient stroke) in either Office for National Statistics (ONS) or SSNAP for each CCG/LHB's patients was used to calculate the CCG/LHB's crude mortality percentage.

99.8% control limits (approximately three standard deviations from the mean) were calculated for all CCGs/LHBs. The control limits for the accompanying funnel plot were calculated using Byar's approximation based on all CCGs/LHBs who directly admitted at least 10 patients with known stroke type.

Following analysis and case mix adjustment the expected number of deaths for each CCG/LHB's patients, and the Standardised Mortality Ratio (SMR) was calculated. Each CCG/LHB’s SMR and the control limits are plotted on the funnel plot overleaf.

| 2016-17 | Patients residing in England and Wales | |---------|---------------------------------------| | Number of patients (with known stroke type) | 81564 | | SMR (Standardised Mortality Ratio) | 1.03 | | Crude mortality | 13.7% | The funnel plot is useful for identifying outliers, taking into account the number of patients per CCG/LHB. What is therefore important is whether the point representing each CCG/LHB lies outside the dotted lines (the funnel). Points inside the funnel represent CCGs/LHBs where the number of observed deaths is not significantly different to the number of expected deaths.

The funnel area of the plot becomes narrower as the number of expected deaths increases because the more patients there are, the less likely variations in the number of deaths are due to chance alone.

For those CCGs/LHBs where the number of observed deaths is significantly higher than the number of expected deaths, their point on the funnel plot lies above the top dotted line. These CCGs/LHBs are outliers at the 99.8% control limit and their SMR in the public table is higher than their upper 99.8% control limit.

To view CCG level mortality results for the year 2016/17 download the CCG and LHB Public Table of Mortality.

Information about the identification, communication and management of outlying organisations in 30-day casemix adjusted mortality results can be downloaded here. Further CCG Indicators

Atrial Fibrillation

*Prior anticoagulation for patients in AF admitted to hospital for stroke*

SSNAP data has revealed major issues in primary and secondary care about ensuring that patients have effective stroke prevention. Over one fifth of patients have a prior diagnosis of atrial fibrillation (AF) on admission. Only 52.8% of patients reported to be in AF on admission were taking anticoagulants between April 2016 and March 2017. For more details on this key indicator see section 1 of this report.

**Early Supported Discharge (ESD)**

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | N=15248 | N=16339 | N=16410 | N=16099 | | | | Percentage of patients known to be in atrial fibrillation when admitted to hospital for stroke and prescribed anticoagulation prior to their stroke | 38.3% | 41.4% | 48.0% | 52.8% | F6.13 |

**Treatment by a stroke skilled Early Supported Discharge team**

ESD can result in better outcomes for patients including reduction of long-term mortality and institutionalisation rates, increased independence six months after a stroke and increased capacity to undertake activities of daily living and greater patient satisfaction (Langhorne et al 2005). For more details on this key indicator see section 1 of this report.

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | Ref | |--------------------------|-------------------------|-------------------------|-------------------------|-------------------------|-----| | N=55868 | N=65774 | N=67835 | N=68605 | | | | Percentage of patients treated by a stroke skilled Early Supported Discharge team | 24.9% | 28.4% | 33.2% | 35.0% | J10.3 |

**Institutionalisation**

Recovery after stroke can be slow and it is important that patients have as much opportunity as possible to recover before a decision is made to discharge them into long-term institutional care. All patients with stroke, other than those who are dying or who have no impairment, should receive physiotherapy, occupational therapy, and speech and language therapy. Randomised controlled trials have shown that institutionalisation rates are lower for those patients discharged with ESD. It is therefore important to analyse the results for each of the indicators included in this report at national and CCG/LHB level as the performance of one standard may impact the results of another.

**Patients discharged alive from hospital who are newly institutionalised**

The tables below shows the age-sex standardised percentage of patients discharged alive from hospital who are newly institutionalised compared to the age and sex profile of patients discharged alive in SSNAP. As institutionalisation is only reported annually, results for this measure cannot be given in section 1 of this report.

| Age-sex standardised percentage of patients discharged alive from hospital who are newly institutionalised compared to the age and sex profile of patients discharged alive in SSNAP | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---|---|---|---|---| | N= 4580 | N=5281 | N=5167 | N=4911 | | 8.2% | 8.0% | 7.6% | 7.2% |

Results for these indicators are available at CCG/LHB level at [www.strokeaudit.org/results/clinical/national-results](http://www.strokeaudit.org/results/clinical/national-results) SSNAP Key Indicators – annual results

44 Key Indicators have been chosen by the Intercollegiate Stroke Working Party (ICSWP) as representative of high quality stroke care. These include data items included in the CCG Outcomes Indicator Set and NICE Quality Standards (covering England only). The key indicators are grouped into 10 domains covering key aspects of the process of stroke care.

Scanning Key Indicators

| Indicator Description | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |--------------------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | 1.1 Percentage of patients scanned within 1 hour of clock start | 41.9% | 44.1% | 47.8% | 51.6% | | 1.2 Percentage of patients scanned within 12 hours of clock start | 84.7% | 88.3% | 91.7% | 93.9% | | 1.3 Median time between clock start and scan (hours:mins) | 1:22 | 1:15 | 1:05 | 0:57 |

Stroke Unit Key Indicators

| Indicator Description | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |--------------------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | 2.1 Percentage of patients directly admitted to a stroke unit within 4 hours of clock start\* | 58.1% | 56.9% | 59.0% | 58.2% | | 2.2 Median time between clock start and arrival on stroke unit (hours:mins) | 3:36 | 3:40 | 3:36 | 3:38 | | 2.3 Percentage of patients who spent at least 90% of their stay on stroke unit | 83.0% | 82.0% | 83.9% | 84.2% |

- From Jan-Mar 2016 onwards patients receiving intra-arterial intervention are excluded from this indicator

### Thrombolysis Key Indicators

| Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | 3.1 Percentage of all stroke patients given thrombolysis (all stroke types) | 11.6% | 11.6% | 11.1% | 11.6% | | 3.2 Percentage of eligible patients (according to the RCP guideline minimum threshold) given thrombolysis | 74.5% | 81.1% | 85.2% | 87.1% | | 3.3 Percentage of patients who were thrombolysed within 1 hour of clock start | 53.0% | 55.9% | 58.4% | 62.1% | | 3.4 Percentage of applicable patients directly admitted to a stroke unit within 4 hours of clock start AND who either receive thrombolysis or have a pre-specified justifiable reason ('no but') for why it could not be given\* | 56.7% | 56.3% | 58.7% | 57.8% | | 3.5 Median time between clock start and thrombolysis (hours:mins) | 0:59 | 0:56 | 0:55 | 0:52 |

- From Jan-Mar 2016 onwards patients receiving intra-arterial intervention are excluded from this indicator.

### Specialist Assessments Key Indicators

| Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | **4.1 Percentage of patients assessed by a stroke specialist consultant physician within 24h of clock start** | 73.8% | 75.8% | 78.8% | 81.3% | | **4.2 Median time between clock start and being assessed by stroke consultant (hours:mins)** | 13:42 | 12:58 | 12:20 | 11:07 | | **4.3 Percentage of patients who were assessed by a nurse trained in stroke management within 24h of clock start** | 86.3% | 87.2% | 89.0% | 90.1% | | **4.4 Median time between clock start and being assessed by stroke nurse (hours:mins)** | 2:15 | 1:47 | 1:26 | 1:12 | | **4.5 Percentage of applicable patients who were given a swallow screen within 4h of clock start** | 63.7% | 68.1% | 72.1% | 74.4% | | **4.6 Percentage of applicable patients who were given a formal swallow assessment within 72h of clock start** | 78.5% | 82.7% | 85.0% | 87.6% |

### Occupational Therapy Key Indicators

| | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |--------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | **5.1 Percentage of patients reported as requiring occupational therapy** | 80.2% | 81.4% | 83.3% | 84.2% | | **5.2 Median number of minutes per day on which occupational therapy is received** | 40.0 | 40.0 | 40.2 | 40.1 | | **5.3 Median % of days as an inpatient on which occupational therapy is received** | 44.8% | 57.0% | 61.4% | 64.0% | | **5.4 Compliance (%) against the therapy target of an average of 25.7 minutes of occupational therapy across all patients** | 55.9% | 72.1% | 80.0% | 84.0% |

*The calculation methods for therapy intensity changed after 1st April 2014 following the addition of new questions to the dataset. Previously, therapy provision was measured out of a patient’s total length of time for which they required any inpatient rehabilitation, but now it is measured out of the period they required the particular therapy for.*

### Physiotherapy Key Indicators

| Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | 6.1 Percentage of patients reported as requiring physiotherapy | 84.7% | 84.7% | 85.5% | 86.0% | | 6.2 Median number of minutes per day on which physiotherapy is received | 31.7 | 33.3 | 33.8 | 35.0 | | 6.3 Median % of days as an inpatient on which physiotherapy is received | 54.3% | 66.6% | 70.0% | 71.9% | | 6.4 Compliance (%) against the therapy target of an average of 27.1 minutes of physiotherapy across all patients *(Target = 45 minutes x (5/7) x 0.85 which is 45 minutes of physiotherapy x 5 out of 7 days per week x 85% of patients)* | 53.2% | 68.8% | 73.9% | 79.2% |

### Speech and Language Therapy Key Indicators

| Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | 7.1 Percentage of patients reported as requiring speech and language therapy | 47.1% | 48.2% | 49.0% | 51.0% | | 7.2 Median number of minutes per day on which speech and language therapy is received | 30.0 | 30.7 | 31.7 | 31.7 | | 7.3 Median % of days as an inpatient on which speech and language therapy is received | 27.5% | 38.8% | 43.3% | 46.9% | | 7.4 Compliance (%) against the therapy target of an average of 16.1 minutes of speech and language therapy across all patients *(Target = 45 minutes x (5/7) x 0.5 which is 45 minutes of speech and language therapy x 5 out of 7 days per week x 50% of patients)* | 24.2% | 35.7% | 41.8% | 47.1% |

### Multidisciplinary Team Working Key Indicators

| Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------------------------------------------------------------------|--------------------------|-------------------------|-------------------------|-------------------------| | **8.1 Percentage of applicable patients who were assessed by an occupational therapist within 72h of clock start** | 86.6% | 88.8% | 90.3% | 91.7% | | **8.2 Median time between clock start and being assessed by occupational therapist (hours:mins)** | 23:50 | 23:23 | 22:10 | **21:43** | | **8.3 Percentage of applicable patients who were assessed by a physiotherapist within 72h of clock start** | 93.4% | 93.8% | 94.1% | **94.7%** | | **8.4 Median time between clock start and being assessed by physiotherapist (hours:mins)** | 22:24 | 22:06 | 21:20 | **21:00** | | **8.5 Percentage of applicable patients who were assessed by a speech and language therapist within 72h of clock start** | 78.0% | 82.1% | 85.6% | **88.6%** | | **8.6 Median time between clock start and being assessed by speech and language therapist (hours:mins)** | 25:25 | 24:51 | 23:49 | **23:09** | | **8.7 Percentage of applicable patients who have rehabilitation goals agreed within 5 days of clock start** | 79.7% | 86.7% | 89.7% | **91.5%** | | **8.8 Percentage of applicable patients who are assessed by a nurse within 24h AND at least one therapist within 24h AND all relevant therapists within 72h AND have rehab goals agreed within 5 days** | 44.3% | 51.5% | 57.1% | **61.1%** |

### Standards by Discharge Key Indicators

| Key Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------|-------------------------|-------------------------|-------------------------|-------------------------| | **9.1** Percentage of applicable patients screened for nutrition and seen by a dietitian by discharge\* | 65.5% | 74.2% | 80.2% | 82.8% | | **9.2** Percentage of applicable patients who have a continence plan drawn up within 3 weeks of clock start | 75.1% | 84.9% | 89.7% | 91.5% | | **9.3** Percentage of applicable patients who have mood and cognition screening by discharge | 78.8% | 86.1% | 89.9% | 91.6% |

- From January 2015 Key Indicator 9.1 has additional exclusion criteria - patients recorded as for palliative care at any point during their inpatient stay are no longer deemed to be applicable for this indicator.

### Discharge Processes Key Indicators

| Key Indicator | April 2013 – March 2014 | April 2014 – March 2015 | April 2015 – March 2016 | April 2016 – March 2017 | |---------------|-------------------------|-------------------------|-------------------------|-------------------------| | **10.1** Percentage of applicable patients receiving a joint health and social care plan on discharge | 69.1% | 81.0% | 87.6% | 90.0% | | **10.2** Percentage of patients treated by a stroke skilled Early Supported Discharge team | 24.9% | 28.4% | 33.2% | 35.0% | | **10.3** Percentage of applicable patients in atrial fibrillation on discharge who are discharged on anticoagulants or with a plan to start anticoagulation | 92.9% | 95.4% | 97.1% | 97.7% | | **10.4** Percentage of those patients who are discharged alive who are given a named person to contact after discharge | 76.7% | 85.8% | 91.0% | 95.7% | Conclusion

This report has presented audit results on the quality of stroke services at national and CCG/LHB level. By presenting both periodic and annual results, changes in performance over time can be monitored carefully. Clinicians, commissioners of stroke services, regulating bodies, and the general public should use this information to highlight where improvements are needed in stroke care and implement action plans to address these issues. This can ensure better provision of stroke care in the future.

It is unprecedented to have collected such a high volume of cases, with good data quality and a representative sample, within five years of initiating a new national audit. In addition, an exceptional turnaround time for rapid public reporting by named hospital is a considerable achievement. The efforts of all the teams and registered audit users participating in SSNAP is highly valued.

SSNAP is now aiming to improve the quality of post-acute data submitted to the audit. We urge all CCG/LHBs to encourage post-acute inpatient teams, domiciliary teams, and six month assessment providers to register and record this vital data on SSNAP to ensure the entire patient pathway is reported on for all stroke patients. Having complete and robust post-acute data will foster improvements to the quality of care and outcomes for patients after they leave hospital.

There are a number of other SSNAP reports publicly available online at www.strokeaudit.org/results that can be used in conjunction with and in addition to the information contained in this report. Of particular interest may be the full CCG/LHB results portfolio which gives named CCG/LHB results for each of the measures included in this report. Any further questions or queries regarding SSNAP can be directed to ssnap@rcplondon.ac.uk. Appendix 1: Breakdown of bandings assigned to CCGs/LHBs

Bandings attributed to CCGs/LHBs for each CCG OIS measure in the August – November 2017 reporting period

### Percentage of eligible patients directly admitted to a stroke unit within 4 hours of clock start

| Banding | Number of CCGs/LHBs attributed each level Aug-Nov 2017 | |------------------|--------------------------------------------------------| | 90.0%+ | 0 (0%) | | 75.0-89.9% | 22 (10%) | | 60.0-74.9% | 87 (41%) | | 55.0-59.9% | 31 (14%) | | Less than 55.0% | 74 (35%) |

### Percentage of all patients who receive thrombolysis

| Banding | Number of CCGs/LHBs attributed each level Aug-Nov 2017 | |------------------|--------------------------------------------------------| | 20.0%+ | 10 (5%) | | 15.0-19.9% | 28 (13%) | | 12.0-14.9% | 48 (22%) | | 10.0-11.9% | 41 (19%) | | Less than 10.0% | 87 (41%) |

### Percentage of applicable patients who are discharged with joint health and social care plan

| Banding | Number of CCGs/LHBs attributed each level Aug-Nov 2017 | |------------------|--------------------------------------------------------| | 90.0%+ | 180 (84%) | | 80.0-89.9% | 11 (5%) | | 75.0-79.9% | 3 (1%) | | 60.0-74.9% | 10 (5%) | | Less than 60.0% | 8 (4%) |

### Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

| Banding | Number of CCGs/LHBs attributed each level Aug-Nov 2017 | |------------------|--------------------------------------------------------| | 90.0%+ | 44 (21%) | | 85.0-89.9% | 77 (36%) | | 80.0-84.9% | 50 (23%) | | 75.0-79.9% | 19 (9%) | | Less than 75.0% | 24 (11%) |

### Percentage of applicable patients who are assessed at 6 months

| Banding | Number of CCGs/LHBs attributed each level | |------------------|------------------------------------------| | 80.0%+ | 16 (7%) | | 60.0-79.9% | 29 (14%) | | 40.0-59.9% | 28 (13%) | | 20.0-39.9% | 44 (21%) | | Less than 20.0% | 97 (45%) |

### Overall SSNAP scores achieved by CCGs/LHBs – changes over time

| SSNAP Score | Aug-Nov 2016 | Dec 2016-Mar 2017 | Apr-Jul 2017 | Aug-Nov 2017 | |-------------|--------------|-------------------|--------------|--------------| | A: 80.0%+ | 55 (25%) | 49 (23%) | 67 (31%) | 54 (25%) | | B: 70.0-79.9%| 56 (26%) | 65 (30%) | 57 (27%) | 92 (43%) | | C: 60.0-69.9%| 64 (30%) | 64 (30%) | 60 (28%) | 39 (18%) | | D: 40.0-59.9%| 36 (17%) | 33 (15%) | 26 (12%) | 25 (12%) | | E: Less than 40.0% | 0 (0%) | 4 (2%) | 2 (1%) | 4 (2%) | | X | 5 (2%) | 1 (\<1%) | 2 (1%) | 0 (0%) | Comparisons between SSNAP Scores achieved by each CCG/LHB for each CCG OIS measure between Apr 2013 – Mar 2014, Apr 2014 – Mar 2015, Apr 2015 – Mar 2016, and Apr 2016 – Mar 2017

### Percentage of applicable patients who go direct to a stroke unit within 4 hours

| Banding | 2013/14 | 2014/15 | 2015/16 | 2016/17 | |---------------|---------|---------|---------|---------| | 90.0%+ | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | | 75.0-89.9% | 21 (10%)| 17 (8%) | 17 (8%) | 14 (6%) | | 60.0-74.9% | 81 (38%)| 84 (39%)| 92 (43%)| 82 (38%)| | 55.0-59.9% | 36 (17%)| 33 (15%)| 37 (17%)| 33 (15%)| | Less than 55.0%| 76 (36%)| 83 (38%)| 70 (32%)| 87 (40%)|

### Percentage of all patients who receive thrombolysis

| Banding | 2013/14 | 2014/15 | 2015/16 | 2016/17 | |---------------|---------|---------|---------|---------| | 20.0%+ | 13 (6%) | 10 (5%) | 4 (2%) | 5 (2%) | | 15.0-19.9% | 35 (16%)| 32 (15%)| 31 (14%)| 24 (11%)| | 12.0-14.9% | 48 (22%)| 66 (30%)| 57 (26%)| 70 (32%)| | 10.0-11.9% | 44 (21%)| 37 (17%)| 44 (20%)| 62 (29%)| | Less than 10.0%| 74 (35%)| 72 (33%)| 80 (37%)| 55 (25%)|

### Percentage of applicable patients who are discharged with joint health and social care plan

| Banding | 2013/14 | 2014/15 | 2015/16 | 2016/17 | |---------------|---------|---------|---------|---------| | 90.0%+ | 60 (30%)| 96 (44%)| 136 (63%)| 145 (67%)| | 80.0-89.9% | 43 (22%)| 58 (27%)| 44 (20%) | 34 (16%) | | 75.0-79.9% | 10 (5%) | 16 (7%) | 11 (5%) | 12 (6%) | | 60.0-74.9% | 34 (17%)| 28 (13%)| 18 (8%) | 19 (9%) | | Less than 60.0%| 53 (27%)| 19 (9%) | 7 (3%) | 6 (3%) |

### Percentage of applicable patients who spend over 90% of their inpatient stay on a stroke unit

| Banding | 2013/14 | 2014/15 | 2015/16 | 2016/17 | |---------------|---------|---------|---------|---------| | 90.0%+ | 36 (18%)| 31 (14%)| 35 (16%)| 37 (17%)| | 85.0-89.9% | 55 (28%)| 58 (27%)| 68 (31%)| 70 (32%)| | 80.0-84.9% | 53 (27%)| 61 (28%)| 65 (30%)| 62 (29%)| | 75.0-79.9% | 32 (16%)| 34 (16%)| 26 (12%)| 24 (11%)| | Less than 75.0%| 24 (12%)| 33 (15%)| 22 (10%)| 23 (11%)|

### Percentage of applicable patients who are assessed at 6 months

| Banding | 2013/14 | 2014/15 | 2015/16 | 2016/17 | |---------------|---------|---------|---------|---------| | 80.0%+ | 5 (2%) | 7 (3%) | 15 (7%) | 16 (7%) | | 60.0-79.9% | 9 (4%) | 20 (9%) | 28 (13%)| 29 (13%)| | 40.0-59.9% | 22 (10%)| 27 (12%)| 34 (16%)| 33 (15%)| | 20.0-39.9% | 20 (9%) | 32 (15%)| 33 (15%)| 44 (20%)| | Less than 20.0%| 158 (74%)| 131 (60%)| 106 (49%)| 94 (44%)|